1-on-1 Life Coaching Interest

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Hello!

I appreciate your interest in exploring life coaching. Life Coaching is about taking an honest assessment of where you are today and how to position yourself to achieve your goals and dreams for your future. I am Kenisha Nichelle, Certified Life Coach, specializing in Grief and Loss Recovery. And let me say, grief and loss doesn't just mean the death of a loved one. It can be experiencing the grief of a missed opportunity or the loss of something you wanted not coming to pass. I want to help you mend the broken pieces of life, so you can live the life you deserve. You should know that I am spiritual-based and utilize the Word of God within my coaching.

Please complete this brief questionnaire so I can better understand your needs. All information provided remains confidential and is for the purpose of allowing me to get to know more about you and how to best serve you while on your journey.

-Kenisha Nichelle

Today's Date *

YYYY

Full Name *

Email Address *

Phone Number *

City and State you reside in *

Date of Birth (Month, Day, Year) *

Marital Status *

Married

Single

Divorced

Widow

In a committed relationship

Do you have children? *

Yes

Current Employment Status *

Full Time/Working from home

Full Time/ In office

Part Time

Self-employed

Unemployed

Student

Are you a student-athlete? *

Yes

Is this your first experience with life coaching or professional support? *

Yes

What issues are you currently facing? *

If you had to choose your level of pain/confusion/frustration as of today (1 not painful to 10 extremely painful), what number would you select? *

What is the most challenging part of your journey through the grief process? (you can select more than one) *

Finding appropriate coping skills

Understanding why the tears come unexpectedly

Having feelings of blame

Processing guilt (thoughts of should of, could of, would of)

Explaining to others what I am feeling

Other:

Required

You acknowledge that there is a financial investment of $65 per life coaching session. You acknowledge that insurance not accepted at this time. *

I acknowledge

Required

Note: I am a Certified Life Coach under the International Coach Federation (ICF), specializing in grief coaching. I am not a therapist, counselor or medical professional. If at any point during our session something is said that I recognize the need for additional attention, our session will be paused and you will be referred to the appropriate professional. *

I acknowledge

Required

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